Provider Demographics
NPI:1669026746
Name:GRANT, DEBRA SUSAN (MFT)
Entity Type:Individual
Prefix:
First Name:DEBRA
Middle Name:SUSAN
Last Name:GRANT
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3301 OCEAN PARK BLVD STE 203
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90405-3230
Mailing Address - Country:US
Mailing Address - Phone:310-396-3877
Mailing Address - Fax:
Practice Address - Street 1:3301 OCEAN PARK BLVD STE 203
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90405-3230
Practice Address - Country:US
Practice Address - Phone:310-396-3877
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-28
Last Update Date:2019-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFT28438106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist